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About Anxiety and Depression

Anxiety and Depression Fact Sheets

Panic Disorder
Generalized Anxiety Disorder
Obsessive-Compulsive Disorder
Social Anxiety Disorder
Post-traumatic Stress Disorder

Jack D. Maser, Ph.D.

Fear and anxiety are a normal part of life, even adaptive in many conditions. Who among us has not studied for a test without some anxiety - and scored better for it? Who has not walked down a dark street in a high crime district without mounting fear? Normal anxiety keeps us alert: it makes us question whether we really have to walk down that street after all.

Mental health professionals are not concerned with normal anxiety. Rather, they attend to fear and anxiety that has somehow gone awry; that inexplicably reaches overwhelming levels; that dramatically reduces or eliminates productivity and significantly intrudes on an individual's quality of life; and for which friends, family, and even the patient can find no obvious cause.

Clinicians recognize about 12 relatively distinct subtypes of anxiety disorder: Panic Disorder, with and without Agoraphobia, Agoraphobia Without a History of Panic Disorder, Specific Phobia, Social Phobia, Obsessive-Compulsive Disorder, Post-traumatic Stress Disorder, Acute Stress Disorder, Generalized Anxiety Disorder, Anxiety Disorder Due to a General Medical Condition, Substance-Induced Anxiety Disorder, and Anxiety Disorder Not Otherwise Specified.

Frequently, these disorders are made more complex and difficult to treat because they are accompanied by depression, substance abuse, and suicidal thoughts. Full definitions of each subtype may be found in The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). American Psychiatric Association, 1994, but the primary distinguishing features will be mentioned briefly here:

  • Panic Disorder- Within 10 minutes, escalating fear develops into a discrete period of intense discomfort accompanied by at least four of 13 somatic or cognitive systems. The afflicted individual believes that he or she is having a heart attack and dying and often presents to a hospital emergency room with this complaint.
  • With Agoraphobia- Often recurrent panic attacks become associated with the places in which they occur. As the person attempts to avoid these places, either in the hope of not triggering an attack or not having help available, or being unable to escape, their freedom of movement and lifestyle may become severely restricted.
  • Without Agoraphobia- Panic attacks occur, but without the consequence of avoidant behavior.
  • Agoraphobia without a History of Panic Disorder Persona with limited symptoms. Panic Attacks or some other symptom(s) that may be incapacitating or embarrassing (e.g. loss of bladder control) may lead to a pervasive avoidance of a variety of situations. Common agoraphobic situations include being in a crowd, crossing a bridge, or leaving home alone. If the person forces exposure to the feared situation, it is only considerable dread.
  • Specific Phobia- Excessive fear upon exposure to a specific object or situation (but not of a panic attack or being embarrassed in a social situation) is the hallmark of a Specific Phobia. When confronted by such objects or events as elevators, funerals, lightning storms, insects, or furry animals, phobic individuals become extremely fearful. Specific phobias may also involve fear of losing control, panicking, and fainting when confronted with the feared object. Adolescents or adults recognize the fear as unreasonable, but can do little to stop it. Often the individual can lead a relatively normal life by simple avoidance, and the diagnosis is not made.
  • Social Phobia- Social Phobic individuals have a persistent fear of exposure to possible scrutiny by others. They fear that they will do something or act in a way that will be humiliating or embarrassing. While it is normal to have some anxiety before an encounter with the boss or before giving a speech, most people are not incapacitated and manage to get through the ordeal. This diagnosis is only made if the consequent avoidant behavior interferes with functioning at work or in usual social situations or if the person is markedly distressed about the problem.
  • Obsessive-Compulsive Disorder (OCD) - Recurrent, distressful obsessions (thoughts) or compulsions can significantly interfere with normal marital, social, or work routines. The person usually recognized the unreasonableness of the behavior, and this fact adds to the distress. However, resisting the obsession or compulsion means that the anxiety will escalate rapidly to intolerable levels. It is easier to give into the intrusive thought or to execute the behavior.
  • Post-Traumatic Stress Disorder (PTSD) - This clinical condition can be traced to a definable, traumatic event in the individual's life.  The individual experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.  It might have occurred within a soldier who served time in a war zone or after witnessing a shooting, being a rape or street crime victim, or living through some natural disaster. The experience must have produced intense fear, helplessness, or horror. Either shortly thereafter or at some later date, the person may experience flashbacks, recurrent and intrusive recollections of the event, feelings of detachment, guild, sleep problems and a variety of somatic symptoms.
  • Acute Stress Disorder- Symptoms, similar to PTSD, that develop within a month after exposure to an extreme traumatic stressor and are time-limited between 2 days and 4 weeks define this disorder.
  • Generalized Anxiety Disorder (GAD) - The individual presented with GAD reports uncontrollable excessive anxiety and worry, more days than not, for at least a 6-month period. They are likely to feel constantly "on edge" and tired, they complain of muscle tenseness, they may be irritable and unable to concentrate, and their sleep pattern is disturbed. The more life circumstances about which the individual worries, the more likely the diagnosis.
  • Anxiety Disorder Due to General Medical Condition- Anxiety symptoms can include those of GAD, panic attacks, or OCD, and these must be directly linked to a general medical condition by the person's history, physical examination or laboratory findings. The anxiety symptoms likely to be atypical for age of onset, course, and family history.
  • Substance-Induced Anxiety Disorder- The clinical presentation of this condition may resemble Panic Disorder, GAD, Phobia, or OCD, but the full set of diagnostic criteria for even one of these disorders does not have to be met. However, it is essential that the anxiety symptoms be due to the direct physiological effects of a drug of abuse, medication, or exposure to a toxin.
  • Anxiety Disorder Not Otherwise Specified- A fair number of people may be expected to fit this category. For example, the DSM-IV clinical trials found a number of people with Mixed Anxiety-Depression (i.e. not meeting full diagnostic criteria for either.) Others who fit this category might be persons with symptoms of Social Phobia who also have dermatological conditions, stuttering problems, and Body Dimorphic Disorder.
The prevalence of these disorders is startling. In any given year, approximately 40 million adults in the United States will suffer from an anxiety disorder. That’s 18% of the adult population. What is especially striking is how many times one or more of these anxiety disorders occur with each other and with other mental disorders, such as depression and substance abuse.

It is important that clinicians and patients recognize that effective treatments are available. Phobias can be treated by behavioral methods, while panic disorder can be treated with medication, cognitive-behavioral therapy or both (see Wolfe and Maser, 1994). Obsessive-Compulsive and Post-traumatic Stress Disorders are difficult but hardly impossible to treat, and the symptoms can be markedly reduced, if not eliminated. When the anxiety disorder is effectively dealt with, drug abuse and secondary depression will also usually decline.

Every year the NIMH spends many millions of dollars on research on the causes and treatments of the anxiety disorders. As understanding of the causes has grown, effective treatments have been developed. Treatment allows afflicted individuals to return to relatively normal, productive lives. Recognition that something is wrong is what brings people to this site. They need to know that once identified, anxiety disorders can be treated.

Causes of Anxiety Disorders

Nature or Nurture?
The National Institute of Mental Health (NIMH) is harnessing the most sophisticated scientific tools available to determine the causes of anxiety disorders. Like heart disease and diabetes, these brain disorders are complex and probably result from a combination of genetic, behavioral, developmental, and other factors.

Studies of twins and families suggest that genes play a role in the origin of anxiety disorders. Although heredity alone can't explain what goes awry. Experience also plays a part. In Post-Traumatic Stress Disorder (PTSD), for example, trauma triggers the anxiety disorder; but genetic factors may explain why only certain individuals exposed to similar traumatic events develop full-blown PTSD. Researchers are attempting to learn how genetics and experience interact in each of the anxiety disorders—information they hope will yield clues to prevention and treatment.

Several parts of the brain are key actors in a highly dynamic interplay that gives rise to fear and anxiety. Much research centers on the amygdala, an almond-shaped structure deep within the brain. The amygdala is believed to serve as a communications hub between the parts of the brain that process incoming sensory signals and the parts that interpret them. It can signal that a threat is present, and trigger a fear response or anxiety. It appears that emotional memories stored in the central part of the amygdala may play a role in disorders involving very distinct fears, like phobias, while different parts may be involved in other forms of anxiety.

Other research focuses on the hippocampus, another brain structure that is responsible for processing threatening or traumatic stimuli. The hippocampus plays a key role in the brain by helping to encode information into memories. Studies have shown that the hippocampus appears to be smaller in people who have undergone severe stress because of child abuse or military combat. This reduced size could help explain why individuals with PTSD have flashbacks, deficits in explicit memory, and fragmented memory for details of the traumatic event.

Also, research indicates that other brain parts called the basal ganglia and striatum are involved in obsessive-compulsive disorder.

By learning more about brain circuitry involved in fear and anxiety, scientists may be able to devise new and more specific treatments for anxiety disorders. For example, it someday may be possible to increase the influence of the thinking parts of the brain on the amygdala, thus placing the fear and anxiety response under conscious control. In addition, with new findings about neurogenesis (birth of new brain cells) throughout life, perhaps a method will be found to stimulate growth of new neurons in the hippocampus in people with PTSD.

How individuals respond to their environment and how the environment responds to them are very important parts of human behavior. Studies are researching the impact of stress, life changes, social factors and other influences on the development of anxiety disorders. The jury is still out, but one thing is certain, the answer requires much study and will take time. The good news is that science has developed many successful treatments for these illnesses.

Causes of Depression
Substantial evidence from neuroscience, genetics, and clinical investigation shows that depressive illnesses are disorders of the brain. However, the precise causes of these illnesses continue to be a matter of intense research.

Modern brain-imaging technologies are revealing that in depression, neural circuits responsible for the regulation of moods, thinking, sleep, appetite, and behavior fail to function properly, and that critical neurotransmitters-chemicals used by nerve cells to communicate-are out of balance. Genetics research indicates that risk for depression results from the influence of multiple genes acting together with environmental or other non-genetic factors. Studies of brain chemistry and the mechanisms of action of antidepressant medications continue to inform our understanding of the biochemical processes involved in depression.

Very often, a combination of genetic, cognitive, and environmental factors are involved in the onset of a depressive disorder. Trauma, loss of a loved one, a difficult relationship, a financial problem, or any stressful change in life patterns, whether the change is unwelcome or desired, can trigger a depressive episode in vulnerable individuals. Later episodes of depression may occur without an obvious cause.

In some families, depressive disorders seem to occur generation after generation; however, they can also occur in people who have no family history of these illnesses. Whether inherited or not, depressive disorders are associated with changes in brain structures or brain function, which can be seen using modern brain imaging technologies.


Treatment of Anxiety Disorders

Effective treatments for each of the anxiety disorders have been developed through research. In general, two types of treatment are available for an anxiety disorder-medication and specific types of psychotherapy (sometimes called "talk therapy"). Both approaches can be effective for most disorders. The choice of one or the other, or both, depends on the patient's and the doctor's preference, and also on the particular anxiety disorder.

Psychiatrists or other physicians can prescribe medications for anxiety disorders. These doctors often work closely with other mental health professionals who provide psychotherapy. Although medications won't cure an anxiety disorder, they can keep the symptoms under control and enable you to lead a normal, fulfilling life. The major classes of medications used for various anxiety disorders are described below.

A number of medications that were originally approved for treatment of depression have been found to be effective for anxiety disorders. If your doctor prescribes an
antidepressant, you will need to take it for several weeks before symptoms start to fade.

Some of the newest antidepressants are called selective serotonin reuptake inhibitors (SSRIs). These medications act in the brain on a chemical messenger called serotonin. They are started at a low dose and gradually increased until they reach a therapeutic level. SSRIs tend to have fewer side effects than older antidepressants. People do sometimes report feeling slightly nauseated or jittery when they first start taking SSRIs, but that usually disappears with time. Some people also experience sexual dysfunction when taking some of these medications. An adjustment in dosage or a switch to another SSRI will usually correct bothersome problems. It is important to discuss side effects with your doctor so that he or she will know when there is a need for a change in medication.

Similarly, antidepressant medications called tricyclic’s are started at low doses and gradually increased. Tricyclic’s have been around longer than SSRIs and have been more widely studied for treating anxiety disorders. For anxiety disorders other than OCD, they are as effective as the SSRIs, but many physicians and patients prefer the newer drugs because the tricyclic’s sometimes cause dizziness, drowsiness, dry mouth, and weight gain. When these problems persist or are bothersome, a change in dosage or a switch in medications may be needed

Monoamine oxidase inhibitors (MAOIs) are the oldest class of antidepressant medications. People who take MAOIs are put on a restrictive diet because these medications can interact with some foods and beverages, including cheese and red wine, which contain the chemical Tyramine. MAOIs also interact with some other medications, including SSRIs. Interactions between MAOIs and other substances can cause dangerous elevations in blood pressure or other potentially life-threatening reactions.

Anti-Anxiety Medications
High-potency benzodiazepines relieve symptoms quickly and have few side effects, although drowsiness can be a problem.  People can develop a tolerance to them-and would have to continue increasing the dosage to get the same effect.  Benzodiazepines are generally prescribed for short periods of time. One exception is panic disorder, for which they may be used for 6 months to a year. People who have had problems with drug or alcohol abuse are not usually good candidates for these medications because they may become dependent on them. Some people experience withdrawal symptoms when they stop taking benzodiazepines, although reducing the dosage gradually can diminish those symptoms. In certain instances, the symptoms of anxiety can rebound after these medications are stopped.

Buspirone, a member of a class of drugs called Azipirones, is a newer anti-anxiety medication that is used to treat GAD. Possible side effects include dizziness, headaches, and nausea. Unlike the benzodiazepines, Buspirone must be taken consistently for at least two weeks to achieve an anti-anxiety effect.

Other Medications
Beta-blockers, such as Propanolol, are often used to treat heart conditions, but have also been found to be helpful in certain anxiety disorders, particularly in social anxiety. When a feared situation, such as giving an oral presentation, can be predicted in advance, your doctor may prescribe a beta-blocker that can be taken to keep your heart from pounding, your hands from shaking, and other physical symptoms from developing

Taking Medication
Before taking medication for an anxiety disorder:
• Ask your doctor to tell you about the effects and side effects of the drug he or she is prescribing.
• Tell your doctor about any alternative therapies or over-the-counter medications you are using.
• Ask your doctor when and how the medication will be stopped. Some drugs can't safely be stopped abruptly; they have to be tapered slowly under a physician's supervision.
• Be aware that some medications are effective in anxiety disorders only as long as they are taken regularly, and symptoms may occur again when the medications are discontinued.
• Work together with your doctor to determine the right dosage of the right medication to treat your anxiety disorder

Psychotherapy involves talking with a trained mental health professional to learn how to deal with problems like anxiety disorders.

Cognitive-Behavioral and Behavioral Therapy Research has shown that a form of psychotherapy that is effective for several anxiety disorders, particularly panic disorder and social anxiety, is cognitive-behavioral therapy (CBT). It has two components. The cognitive component helps people change thinking patterns that keep them from overcoming their fears. For example, a person with panic disorder might be helped to see that his or her panic attacks are not really heart attacks as previously feared; the tendency to put the worst possible interpretation on physical symptoms can be overcome.

The behavioral component of CBT seeks to change people's reactions to anxiety-provoking situations. A key element of this component is exposure, in which people confront the things they fear. An example would be a treatment approach called exposure and response prevention for people with OCD. If the person has a fear of dirt and germs, the therapist may encourage them to dirty their hands and then go a certain period of time without washing. The therapist helps the patient to cope with the resultant anxiety. Eventually, after this exercise has been repeated a number of times, anxiety will diminish.

A major aim of CBT and behavioral therapy is to reduce anxiety by eliminating beliefs or behaviors that help to maintain the anxiety disorder. CBT or behavioral therapy generally lasts about 12 weeks. It may be conducted in a group, provided the people in the group have sufficiently similar problems. Group therapy is particularly effective for people with social phobia.

Medication may be combined with psychotherapy, and for many people this is the best approach to treatment. As stated earlier, it is important to give any treatment a fair trial.  If one approach doesn't work, the odds are that another one will, so don't give up.

If you have recovered from an anxiety disorder, and at a later time it recurs, don’t consider yourself a “treatment failure”. Recurrences can be treated effectively, just like an initial episode. In fact, the skills you learned in dealing with the initial episode can be helpful in coping with a setback.

Solution-Focused Therapy

Solution-focused therapy is a future–oriented, goal-directed approach that focuses on solutions, rather than the problems that brought one to treatment (Institute for Solution-Focused Therapy).

Below is a list of some of the problems that can be resolved using solution-focused therapy:

  • Panic attacks
  • A phobia
  • Mild Depression
  • A relationship problem
  • Conflict with a family member or members
  • Difficulty making an important decision
  • Budgeting/Financial difficulties
  • Wanting assistance in making a lifestyle change such as losing weight, quitting smoking, eating healthier, changing careers or going back to school

Treatment of Depressive Illnesses

Diagnostic Evaluation and Treatment

The first step to getting appropriate treatment for depression is a physical examination by a physician. Certain medications as well as some medical conditions such as a viral infection, thyroid disorder, or low testosterone level can cause the same symptoms as depression, and the physician should rule out these possibilities through examination, interview, and lab tests. If no such cause of the depressive symptoms is found, a psychological evaluation for depression should be done by the physician or by referral to a mental health professional.

A good diagnostic evaluation will include a complete history of symptoms, i.e., when they started, how long they have lasted, how severe they are, whether the patient had them before and, if so, whether the symptoms were treated and what treatment was given.

The doctor should ask about alcohol and drug use, and if the patient has thoughts about death or suicide. Further, a history should include questions about whether other family members have had a depressive illness and, if treated, what treatments they may have received and if they were effective. Last, a diagnostic evaluation should include a mental status examination to determine if speech, thought patterns, or memory has been affected, as sometimes happens with depressive disorders.

There are several types of medications used to treat depression. These include newer antidepressant medications – chiefly the selective serotonin reuptake inhibitors (SSRIs)-and older ones-the tricyclic’s and the monoamine oxidase inhibitors (MAOIs). The SSRI’s, and other newer medications that affect neurotransmitters such as dopamine or norepinephrine, generally have fewer side effects than tricyclic’s. Sometimes the doctor will try a variety of antidepressants before finding the most effective medication or combination of medications for the patient. Sometimes the dosage must be increased to be effective. Although some improvements may be seen in the first couple of weeks, antidepressant medications must be taken regularly for three to four weeks (in some cases, as many as eight weeks) before the full therapeutic effect occurs.

Patients often are tempted to stop medication too soon. They may feel better and think they no longer need the medication, or they may think it isn’t helping at all. It is important to keep taking medication until it has a chance to work, though side effects (see section on Side Effects) may appear before antidepressant activity does. Once the person is feeling better, it is important to continue the medication for at least four to nine months to prevent a relapse into depression. Some medications must be stopped gradually to give the body time to adjust, and many can produce withdrawal symptoms if discontinued abruptly. Therefore, medication should never be discontinued abruptly without talking to your doctor about it first.  For individuals with bipolar disorder and those with chronic or recurrent major depression, medication may have to be maintained indefinitely.

Medications for depressive disorders are not habit forming. Nevertheless, as is the case with any type of medication prescribed for more than a few days, these treatments have to be carefully monitored to see if the most effective dosage is being given. The doctor will check the dosage of each medicine and its effectiveness regularly.

For the small number of people for who MAO inhibitors are the best treatment, it is necessary to avoid certain foods that contain high levels of Tyramine, including many cheeses, wines, and pickles, as well as medications such as decongestants. The interaction of Tyramine with MAOIs can bring on a hypertensive crisis, a sharp increase in blood pressure that can lead to a stroke. The doctor should furnish a complete list of prohibited foods that the patient should carry at all times. Other forms of antidepressants require no food restrictions. Efforts are underway to develop a “skin patch” system for one of the newer MAOIs, Selegiline; if successful; this may be a more convenient and safer medication option than the older MAOI tablets. Treatment choice will depend on the patient’s diagnosis, severity of symptoms, and preference. There are a variety of treatments, including medications and short-term psychotherapies (i.e., “talking” therapies), that have been proven to be effective for treating depressive disorders. In general, severe depressive illnesses, particularly those that are recurrent, will require a combination of treatments for the best outcomes.

Medications of any kind – prescribed, over-the-counter, or borrowed – should never be mixed without consulting a doctor. Other health professionals, such as a dentist or other medical specialist, who may prescribe a drug, should be told of the medications the patient is taking. Some medications, although safe when taken alone can, if taken with others, cause severe and dangerous side effects.

Alcohol, including wine, beer, and hard liquor, or street drugs may reduce the effectiveness of antidepressants and should be avoided. However, some people who have not had a problem with alcohol abuse or dependence may be permitted by their doctor to use a modest amount of alcohol while taking one of the newer antidepressants.

Anti-anxiety drugs or sedatives are not antidepressants. They are sometimes prescribed along with antidepressants, but they are not effective when taken alone for a depressive disorder. Stimulants, such as amphetamines, are also not effective antidepressants, but they are used occasionally under close supervision in medically ill-depressed patients.

Treatment for Bipolar Disorder
Research has shown that people with bipolar disorder are at risk of switching to mania, or of developing rapid cycling episodes, during treatment with antidepressant medication. Therefore, “mood-stabilizing” medications generally are required, alone or in combination with antidepressants, to protect people with bipolar disorder from this switch. Lithium and valproate (Depakote®) are the most commonly used mood-stabilizing drugs today. If a person has preexisting thyroid, kidney, or heart disorders or epilepsy, lithium may not be recommended. Fortunately, other medications have been found to be of benefit in controlling mood swings. Among these are two mood-stabilizing anticonvulsants, valproate (Depakote®) and carbamazepine (Tegretol®). Both of these medications have gained wide acceptance in clinical practice, and valproate has been approved by the Food and Drug Administration for first-line treatment of acute mania. Other anticonvulsants that are being used now include lamotrigine (Lamictal®), topiramate (Topamax®), and gabapentin (Neurontin®); however, their role in the treatment of bipolar disorder is not yet proven and remains under study.

Most people who have bipolar disorder take more than one medication including, along with lithium and/or an anticonvulsant, a medication for accompanying agitation, anxiety, depression, or insomnia. Finding the best possible combination of these medications is of utmost importance to the patient and requires close monitoring by the physician.

Questions about any medication prescribed, or problems that may be related to it, should be discussed with your doctor.

Several forms of psychotherapy, including some short-term (10-20 weeks) therapies, can help people with depressive disorders. Two of the short-term psychotherapies that research has shown to be effective for depression are cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT). Cognitive-behavioral therapist’s help patients change the negative thinking and behavior patterns that contribute to or result from depression. Through verbal exchange with the therapist, as well as “homework” assignments between therapy sessions, CBT helps patients gain insight into and resolve problems related to their depression. Interpersonal therapists help patients work through disturbed personal relationships that may be contributing to or worsening their depression. Psychotherapy is offered by a variety of licensed mental health providers, including psychiatrists, psychologists, social workers, and mental health counselors.

For many depressed patients, especially those with moderate to severe depression, a combination of antidepressant medication and psychotherapy is the preferred approach to treatment. Some psychiatrists offer both types of intervention. Alternatively, in many cases two mental health professionals collaborate in the treatment of a person with depression; for example, a psychiatrist or other physician, such as a family doctor, may prescribe medication while a nonmedical therapist provides ongoing psychotherapy.

Electroconvulsive Therapy
Electroconvulsive Therapy (ECT) is another treatment option that may be particularly useful for individuals whose depression is severe or life threatening, or who cannot take antidepressant medication. ECT often is effective in cases where antidepressant medications do not provide sufficient relief of symptoms. The exact mechanisms by which ECT exerts its therapeutic effect are not yet known.

In recent years, ECT has been much improved. A muscle relaxant is given before treatment, which is done under brief anesthesia. Electrodes are placed at precise locations on the head to deliver electrical impulses. The stimulation causes a brief (about 30 seconds) generalized seizure within the brain, which is necessary for therapeutic efficacy. The person receiving ECT does not consciously experience the electrical stimulus.

A typical course of ECT entails 6 to 12 treatments, administered at a rate of three times per week, on either an inpatient or an outpatient basis. To sustain the response to ECT, continuation treatment, often in the form of antidepressant and/or mood stabilizer medication, must be instituted. The exact mechanisms by which ECT exerts it therapeutic effect are not yet known. Some individuals may require maintenance ECT, which is delivered on an outpatient basis at a rate of one treatment weekly to as infrequently as monthly. The most common side effects of ECT are confusion and memory loss for events surrounding the period of ECT treatment. The confusion and disorientation experienced upon awakening after ECT typically clear within an hour. More persistent memory problems are variable and can be minimized with the use of modern treatment techniques, such as application of both stimulus electrodes to the right side of the head (unilateral ECT).